• Alcoholics, the heaviest of drinkers, are also the heaviest of smokers.
• A recent study found that nicotine is especially rewarding in smokers in recovery from alcoholism compared to smokers with no history of alcoholism.
• Smokers who are former alcoholics probably require special help to deal with nicotine addiction when they try to stop smoking.

It’s no secret that "smokers drink and drinkers smoke." In fact, the heaviest drinkers are also the heaviest smokers. According to information provided by the National Institute on Alcohol Abuse and Alcoholism, between 80 and 95 percent of alcoholics smoke cigarettes, a rate that is three times higher than among the population as a whole. Approximately 70 percent of alcoholics are heavy smokers (meaning they smoke more than one pack a day), compared with just 10 percent of the general population. A study in the November issue of Alcoholism: Clinical & Experimental Research closely examines this association to see if smokers with a past history of alcoholism are more nicotine dependent than smokers with no such history.

"There are many theories of why smoking and alcoholism go together," said John R. Hughes, professor of psychiatry at the University of Vermont/Fletcher Allen Healthcare and lead author of the study. "Some studies suggest that the same genes that predispose people to alcoholism also predispose them to smoking. Some have thought there is an ‘addictive personality’ that becomes addicted to many things, but research suggests this is not so. Another idea is that since smoking stimulates and alcohol relaxes, smokers use alcohol to prevent over-stimulation from smoking and alcoholics use cigarettes to prevent sedation. Yet another idea is that those who become alcoholics are people who use substances for the drugs within them, for example, to get high or to cope with life. This theory would predict that alcoholic smokers use tobacco mostly for the nicotine in it."

Hughes’ study examined if smokers with a past history of alcoholism would report more positive effects from nicotine alone (using nicotine gum) and would self-administer nicotine more often and in greater amounts than smokers without this history. What they found was that smokers with a history of alcoholism did not report more positive effects from nicotine itself, but these smokers did more often choose to use pure nicotine, and ingested greater levels of nicotine than smokers without this history. This means that smokers with a history of alcoholism didn’t necessarily like nicotine more, but they did seem to find nicotine more rewarding.

"It may seem unusual," explained Hughes, "that we found a difference between the self-administration or rewarding effects of nicotine and the subjective effects or the liking of nicotine. Usually these two go hand in hand, but not always. In fact, many smokers state they can't understand their use of cigarettes because they feel they really don’t get much out of it. Sometimes we can like something but not be able to express what it is we like about it. It’s like husbands. If you went by their words, many husbands would seem not to be much in love with their wives. But if you went by what they do, they would seem very much in love."

Despite the strong association between smoking and alcoholism, and numerous theories concerning that association, relatively few studies have examined the two together. Furthermore, alcoholism treatment professionals have generally not addressed the issue of smoking cessation, largely because of the belief that the added stress of quitting smoking might jeopardize an alcoholic’s recovery.

"Research attention has been minor until recently," acknowledged Kenneth A. Perkins, professor of psychiatry at the University of Pittsburgh Medical Center. "Many in the alcohol field did not feel smoking was an important problem for alcoholics, that maintaining sobriety was the critical factor. Most studies in the smoking field would exclude those with current or past alcohol dependence. Furthermore, funding has typically come from different agencies – one for alcohol, another for smoking/nicotine – which allowed studies of alcohol and smoking to fall through the cracks."

Yet, noted Hughes, recent data indicates that smoking actually kills more alcoholics than alcohol does. Indeed, according to the American Cancer Society, smoking is the most preventable cause of death in American society. Nearly one in five deaths in the U.S. results from the use of tobacco; more than 400,000 die from smoking in the U.S. each year.

"What this means," said Hughes, "is that we need to get alcoholics to stop smoking either while stopping their alcohol or soon after. Our study suggests these smokers especially need to use medications that fight nicotine dependence, like the patch, gum, an inhaler, or Zyban." (Zyban is the trade name for an anti-depressant that is used by some to quit smoking.)

Perkins concurs. "This study shows us that chronic use of alcohol can induce long-term changes in the brain's response to nicotine, making nicotine more rewarding and thus more difficult to quit," he said. "Medications to block these effects, or counseling to totally avoid nicotine exposure, may be suggested by these results. Although someone might think that use of nicotine replacement therapy (NRT) would pose a problem for those with past history of alcohol, this is not a reasonable concern. NRT is safe and effective, and someone with alcohol problems should not be concerned about using NRT to quit smoking. In fact," he added, "alcoholics are at least as likely to die from smoking as from alcohol. Treatment for smoking in that population is critical."

Hughes, J.R., Rose, G.L., Callas, P.W. (2000). Nicotine is More Reinforcing in Smokers With a Past History of Alcoholism Than in Smokers Without This History. Alcoholism: Clinical & Experimental Research, November, 24(10), 1633-1638.